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This was an administrative case involving a licensed physician assistant, who was employed as a PA at the Weems Hospital Emergency Department in Apalachicola but whose supervising physician was 500 miles away in Miami. While the Weems ED had a Medical Director, DOH records did not indicate that he was a supervising physician for Carmouze.
On June 7, an 85-year-old patient in respiratory distress, with a history of congestive heart failure, coronary artery disease and atrial fibrillation, was referred to the Weems ED by her cardiologist.
Carmouze was on duty at the time and responsible for treating the patient.
Carmouze ordered nebulizer treatments for the patient, but her condition quickly deteriorated. Soon after arrival, the patient went into respiratory arrest, followed shortly by cardiac arrest. Carmouze did not attempt endotracheal intubation to open the patient’s airway until after she was in cardiac arrest. Concerned that appropriate care was not being provided, an ED nurse contacted the patient’s cardiologist who arrived shortly thereafter to attempt resuscitation himself. Unfortunately, his attempts were unsuccessful.
Allegation: Practicing beyond the scope of practice permitted by law, F.S.
§458.347(2)(e).
Analysis:
DOH investigated the above case and reviewed an additional 120 records of patients treated by Carmouze at the Weems Hospital Emergency Department from April 22 June 12, 2002 and found the following:
(A). None of the records reviewed contained documentation that the supervising physician had supervised or delegated the performance of any medical services to him.
(B) There was no evidence of any retrospective reviews by his supervising physician or of any telephone consultations.
(C) Carmouze did not practice within reasonable proximity to supervising physician. Generally, the Florida Administrative Code only requires “indirect supervision” of PA practice (F.A.C. §64B30.012). DOH rules (F.A.C. §64B-30.001) define indirect supervision as easy availability of the supervising physician and require the supervising physician to be within reasonable physical proximity.
(D) The medical records did not identify the supervising physician by name and professional title, as required by statute,
F.S. §458 331(1)(m), nor were tasks and procedures reviewed, signed and dated by the supervising physician within 30 days, as required.
DOH concluded that Carmouze had “demonstrated a flagrant disregard for the duties and responsibilities imposed upon a physician assistant practicing in the State of Florida.” They also concluded that he had “manifested] such a pattern and propensity to practice … outside of the scope permitted” that there was a high probability that the pattern would continue, posing an immediate serious danger to the health, safety and welfare of the public.
Consequently, Mr. Carmouze’s license was restricted to prohibit him from practicing as a PA without the direct (on-site) supervision of a supervising physician.
DOH’s disciplinary action in this case is based on rather egregious circumstances a PA whose supervising physician practiced 500 miles away and whose records did not indicate any evidence of review for more than 7 weeks. While there has not been any action taken against the supervising physician of record as of yet, the rules cited establish physician supervisory responsibilities as well as a scope of practice for PAs.
Risk Reduction Strategies:
assure that there is evidence of a “review” of all the tasks and procedures performed in the review time period as a simple signature at the end of voluminous notes may not suffice as adequate evidence.
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1. This case indicates the importance of both the practical aspects and the documentation aspects of supervision. While the supervising physician need not be on site while a PA provides most services, s/he does need to be available by phone and within reasonable physical distance to permit her/him to timely and personally attend to the patient if necessary. In assessing the “reasonableness” of the proximity of the supervising physician, the PA and the physician should consider the nature and location of the services being provided (including vulnerability of the patient population), the probability that assistance will be required, and the risk of the tasks/procedures being performed.
2. DOH requires that a supervising physician must review PA records “within” 30 days. The rule should be not be seen as establishing a set interval, but rather as establishing a maximum interval. A prudent approach would be to assess the nature of the services and patient population needs and decide on what frequency is appropriate, with the maximum allowable being 30 days. While DOH may not take action based on violation of the rule if review occurs every 30 days, a medical malpractice action may be based on the argument that the physician should have reviewed more frequently, given the illnesses and/or population of the practice. The PA and supervising physician should. 
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